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DSS-II bariatric recommendations

DSS-II bariatric recommendations should replace NIH guidelines

These new guidelines have been formally ratified by 53 leading diabetes and surgery societies worldwide

The recommendations regarding bariatric surgery from the Diabetes Surgery Summit (DSS-II) consensus conference in London, September 2015, should replace the National Institutes of Health (NIH) suggestions that have governed bariatric surgery practice and insurance compensation worldwide since 1991, according to a paper published in Diabetologia. The current NIH guidelines state recommend patients should qualify for bariatric surgery if they have inadequately controlled diabetes and a BMI>35, the DSS-II state that surgery should be recommended for patients with inadequately controlled diabetes and a BMI as low as 30 or 27.5 for Asian individuals. The DSS-II guidelines that have been endorsed by 53 organisations worldwide, and were subsequently incorporated into the American Diabetes Association Standards of Diabetes Care in 2017.

“This conclusion is based on biological and clinical rationales. For example, mechanistic studies demonstrate that surgical manipulation of the gastrointestinal tract can exert powerful, beneficial effects on various facets of glucose homeostasis, independent of weight loss,” the paper states. “Moreover, a large body of clinical evidence, including numerous randomised clinical trials, documents that surgery improves blood glucose levels more effectively than any lifestyle and/or pharmaceutical intervention, often yielding long-term diabetes remission.”

In the paper, ‘Metabolic surgery for the treatment of type 2 diabetes in obese individuals’, by Dr David E Cummings from the University of Washington and VA Puget Sound Health Care System, Seattle, USA, and Professor Francesco Rubino, King’s College London and King’s College Hospital, London, UK, they review evidence regarding the effects of metabolic surgery in patients with obesity and type 2 diabetes, discussing the clinical, biological and economic rationales that support expanding its use as part of modern multidisciplinary approaches to diabetes care.

Evidence gaps

Despite the increase in research on the benefits of metabolic surgery in patients with obesity and type 2 diabetes in the literature, the authors highlight numerous evidence gaps and key domains that require additional research including:

  • Long-term (>5 year) results from randomised clinical trials (level 1a evidence)
  • Longer-term data (>10 years) are needed on efficacy and safety using non-randomised studies examining the operations currently performed.
  • Level 1 evidence is needed to measure hard outcomes, such as microvascular and/or macrovascular events, cancer, death, etc.
  • More evidence is warranted regarding the long-term risks after intestinal bypass operations for metabolic bone disease, osteoporosis and fractures, especially from operations most commonly performed today.
  • Cost-effectiveness data from large randomised clinical trials, rather than just modelling methodologies.
  • Research comparing diabetes medications such as glucagon-like peptide-1 (GLP-1) agonists and sodium–glucose cotransporter (SGLT) 2 against metabolic surgery in randomised clinical trials with ‘hard’ endpoints.
  • Level 1 evidence is needed regarding the long-term (>5 year) rates of weight regain and diabetes recurrence after sleeve gastrectomy, which is now the most commonly performed bariatric/metabolic operation in many countries.
  • Further research on combining metabolic surgery and intensive medical/lifestyle treatments.

“The 32 new DSS-II consensus statements and guidelines identify metabolic surgery as a standard option in the type 2 diabetes treatment algorithm (Figure 1),” the paper concludes. “…Although this change in BMI threshold is a modest numerical modification, it encompasses a very large number of people. In the USA, ~43% of individuals with diabetes have a BMI of 30–35 kg/m2 and, worldwide, the vast majority of people with diabetes have a BMI <35 kg/m2, including >98% of East Asian individuals.”

Figure 1: DSS-II: surgery in the type 2 diabetes treatment algorithm. Algorithm for the treatment of type 2 diabetes, including the option of bariatric/metabolic surgery, as recommended by DSS-II voting delegates

To access this paper, pleas click here

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